netstudy2.dhs.state.mn.us Open in urlscan Pro
136.234.168.90  Public Scan

Form analysis
2 forms found in the DOM

POST #

<form id="__AjaxAntiForgeryForm" action="#" method="post">
  <input name="__RequestVerificationToken" type="hidden" value="H8Oo_lJ62O7bZQQ9dg2urhZXZvDLZkYoT-5WwAN6cB3lwRVicFE91ZAIQO-i-CSJgu96OCWIV58IJrywgUK95P51IQOpcJyepD_8hquPiJQ1">
</form>

POST /Applicant/

<form action="/Applicant/" autocomplete="off" id="pageForm" method="post" novalidate="novalidate"><input name="__RequestVerificationToken" type="hidden"
    value="HPBbDKi4IiNvx8fioXBK3n0ApI0k5ToSoSjyOqIQiScF-G1RhD-RJFeBZ3o7XMZItgwOm8DI79Utor-JoFoAZ4D2TU9_D6uF6SN9gUgZo501">
  <fieldset>
    <legend></legend>
    <div class="form-group">
      <div class="">
        <label><span class="required">*&nbsp;</span>First Name:<br><input class="form-control" data-val="true" data-val-length="Maximum 50 characters" data-val-length-max="50" data-val-regex="Invalid characters"
            data-val-regex-pattern="^[A-Za-z]+[ A-Za-zíóéáñ'-\.]*$" data-val-required="(required)" id="FirstName" maxlength="50" name="FirstName" tabindex="0" type="text" value=""><span class="field-validation-valid" data-valmsg-for="FirstName"
            data-valmsg-replace="true"></span></label>
      </div>
      <div class="">
        <label><span class="required">*&nbsp;</span>Last Name:<br><input class="form-control" data-val="true" data-val-length="Maximum 50 characters" data-val-length-max="50" data-val-regex="Invalid characters"
            data-val-regex-pattern="^[A-Za-z]+[ A-Za-zíóéáñ'-\.]*$" data-val-required="(required)" id="LastName" maxlength="50" name="LastName" tabindex="0" type="text" value=""><span class="field-validation-valid" data-valmsg-for="LastName"
            data-valmsg-replace="true"></span></label>
      </div>
    </div>
    <div class="form-group">
      <div class="">
        <label><span class="required">*&nbsp;</span>Date of Birth:<br><input class="form-control datew" data-val="true" data-val-required="(required)" id="DateOfBirth" name="DateOfBirth" tabindex="0" type="text" value=""><span
            class="field-validation-valid" data-valmsg-for="DateOfBirth" data-valmsg-replace="true"></span></label>
      </div>
      <div class="">
        <label>Social Security Number:<br><input class="form-control" data-val="true" data-val-length="Maximum 11 characters" data-val-length-max="11" data-val-regex="Invalid SSN"
            data-val-regex-pattern="^(?!219-09-9999|078-05-1120)(?!666|000)\d{3}-(?!00)\d{2}-(?!0{4})\d{4}$" id="Ssn" maxlength="11" name="Ssn" tabindex="0" type="text" value=""><span class="field-validation-valid" data-valmsg-for="Ssn"
            data-valmsg-replace="true"></span></label>
      </div>
    </div>
    <div class="form-group">
      <div class="">
      </div>
      <div class="">
        <label>Determination ID Code:<br><input class="form-control" id="DeterminationId" name="DeterminationId" tabindex="0" type="text" value=""></label>
      </div>
      <div class="">
      </div>
    </div>
    <div class="form-group">
      <div class="">
        <label><span class="required">*&nbsp;</span>Email:<br><input class="form-control" data-val="true" data-val-length="Maximum 128 characters" data-val-length-max="128" data-val-regex="Please enter a valid email address in the form xxx@yyy.zzz"
            data-val-regex-pattern="^[a-zA-Z0-9.!#$%&amp;'*\+\-/=?\^_`{|}~-]+@[a-zA-Z0-9&amp;+-_]+(\.([a-zA-Z0-9-]+)+)+$" data-val-required="(required)" id="Email" maxlength="128" name="Email" tabindex="0" type="text" value=""><span
            class="field-validation-valid" data-valmsg-for="Email" data-valmsg-replace="true"></span></label>
      </div>
    </div>
    <div class="form-group">
      <div class="">
        <label><span class="required">*&nbsp;</span>Confirm Email:<br><input class="form-control" data-val="true" data-val-length="Maximum 128 characters" data-val-length-max="128"
            data-val-regex="Please enter a valid email address in the form xxx@yyy.zzz" data-val-regex-pattern="^[a-zA-Z0-9.!#$%&amp;'*\+\-/=?\^_`{|}~-]+@[a-zA-Z0-9&amp;+-_]+(\.([a-zA-Z0-9-]+)+)+$" data-val-required="(required)" id="ConfirmEmail"
            maxlength="128" name="ConfirmEmail" tabindex="0" type="text" value=""><span class="field-validation-valid" data-valmsg-for="ConfirmEmail" data-valmsg-replace="true"></span></label>
      </div>
    </div>
    <div class="form-group">
      <div class="">
        <label><span class="required">*&nbsp;</span>Phone:<br><input class="form-control" data-val="true" data-val-regex="Invalid Phone Number"
            data-val-regex-pattern="^(\(?\d\d\d\)?)?( |-|\.)?\d\d\d( |-|\.)?\d{4,4}(( |-|\.)?[eExXtT\.]+ ?\d+)?[ \t]*$" data-val-required="(required)" id="Phone" name="Phone" tabindex="0" type="text" value=""><span class="field-validation-valid"
            data-valmsg-for="Phone" data-valmsg-replace="true"></span></label>
      </div>
    </div>
    <div class="form-group">
      <div class="">
        <div><label for="PhoneTypeId">Phone Type:<br><select class="form-control" data-val="true" data-val-optional="(required)" id="PhoneTypeId" name="PhoneTypeId" tabindex="0">
              <option value=""></option>
              <option value="11119">Home</option>
              <option value="11120">Work</option>
              <option value="11121">Mobile</option>
            </select><span class="field-validation-valid" data-valmsg-for="PhoneTypeId" data-valmsg-replace="true"></span></label></div>
      </div>
    </div>
    <div id="errorMessageDiv" class="form-group">
      <div class="">
        <span id="errorMessageSpan" style="color:red; display:none"></span>
      </div>
    </div>
    <div class="form-group">
      <div class="text-right">
        <button type="button" class="btn btn-secondary" id="cancelRegister">Cancel</button>
        <button type="button" class="btn btn-primary" id="register" data-url="/Applicant/Auth/Register">Register</button>
      </div>
    </div>
  </fieldset>
</form>

Text Content

REGISTER AS NEW USER

New Providers. Do not use this site if you are in the process of establishing a
new account through the NETStudy 2.0 Onboarding and New Account Access Tool. Use
of your email address on this site will stop your onboarding.

Social Security Number. Your Social Security Number (SSN) is not required but
including it benefits you by:

 * Making determinations potentially available to future entities. This may also
   reduce the need to be fingerprinted again.
 * Making application documents automatically connect to your Applicant Portal
   account. 

Enter your SSN now to receive these benefits. You cannot add your SSN after your
registration is complete.

Verify Your Information. Submission of accurate information is important. Your
name and date of birth must match your legal identification. Inaccurate
information may cause your background study to be invalid.

User Account. The email address used to create your account is your username.
You cannot change your username after your registration is complete.




* First Name:

* Last Name:

* Date of Birth:

Social Security Number:

Determination ID Code:


* Email:

* Confirm Email:

* Phone:

Phone Type:
Home Work Mobile

Cancel Register

CONFIRM REGISTRATION

×

Please confirm that you want to create an Applicant Data Entry Portal account by
selecting "Confirm Registration."

Confirm Registration Cancel